Program Profile: Assisted Outpatient Treatment (AOT)

This is a court-ordered treatment program for individuals with mental illness who have a history of multiple hospitalizations or have exhibited violence toward themselves or others. The program is rated Promising. Participants who received treatment had a statistically significant reduction in risk for arrests of any offense, compared with the comparison group. However, there was no statistically significant difference found between the groups in risk of arrests for violent offenses.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals

In 1999, Kendra’s Law, a statutory framework passed in New York State, established the court-ordered Assisted Outpatient Treatment (AOT), also known as outpatient commitment (OPC). AOT is mental health intervention that provides community-based services to individuals diagnosed with a mental illness and have a history of multiple hospitalizations or have exhibited violence toward themselves or others. The goal of AOT is to reduce arrests for any offense and especially violent offenses.

Target Population

In New York State, AOT targets individuals (18 and older) diagnosed with a mental illness, who are capable of living in the community with the help of family, friends, and mental health professionals. However, without routine care and treatment, these individuals may relapse and become violent or suicidal or require hospitalization (New York State Office of Mental Health 2005). In order for the court to mandate AOT, the petitioners must establish that the individuals meet specific legal and clinical eligibility criteria, including having 1) a history of treatment noncompliance, whereby they are considered unlikely to voluntarily adhere to treatment; and 2) a high likelihood of benefiting from the mandated treatment, especially if they are at risk for relapse or deterioration that would result in physical harm to themselves or others and are unable to take responsibility for their own care (New York State Office of Mental Health 2005).

Program Components

Kendra’s Law established mechanisms so that local mental health systems give individuals entering AOT priority access to case management and enhanced services (including housing and vocational services) that are essential to treating an individual’s mental illness, avoiding relapse that would lead to harm or re-hospitalization, and helping the individual live in the community.

Mandatory treatment plans are developed and implemented to ensure comprehensive, community-based services are provided to AOT recipients. There is a wide range of services provided, including case management, medication management, individual or group therapy, day programs, substance abuse services, housing or housing support services, and urine or blood toxicology tests (to ensure adherence to medication).

No court order goes into effect unless a treatment plan has been submitted to the court. The court cannot add anything to the proposed treatment plan but can reduce or eliminate treatment mandates. The length of the court order can vary by individual. Some court orders last 6 months or less, while others are in place for longer than 6 months. When the court order expires, individuals are moved to a voluntary agreement when they transition from AOT, maintaining the same level of enhanced services for 6 months. Afterwards, they are moved out of the formal AOT program, although they may continue to receive services as needed. Although Kendra’s Law does not include specific enforcement provisions, noncompliance with an AOT court order can be a factor in a physician’s consideration of an evaluation for involuntary hospitalization (New York State Office of Mental Health 2005; Gilbert et al. 2010).

Study

Link and colleagues (2011) conducted a quasi-experimental study that examined the impact of the Assisted Outpatient Treatment (AOT) intervention, established in New York State in 1999 through ?Kendra?s Law.? Eligibility for the court- mandated AOT intervention was based on the following legal criteria: 1) the individual had a history of treatment noncompliance, whereby the individual is considered unlikely to voluntarily adhere to treatment; and 2) the individual has a high likelihood of benefiting from the mandated treatment. The New York State Office of Mental Health records were used to accurately identify periods in which individuals were assigned to AOT. Participants were recruited from outpatient clinics in the New York City boroughs of the Bronx and Queens (n = 183).

Of the 183 participants, 86 were assigned to the treatment group (individuals who had at some point in their lives received AOT), and 97 were assigned to the comparison group (individuals who had never received AOT at any point). Sixty percent of the total sample population was male, with an average age of 37 years. Of these participants, 54 percent were African American, 29 percent were Hispanic, and 18 percent were white or other. Patient data reported that 70 percent of the total sample had a psychotic disorder diagnosis, 25 percent had a mood disorder diagnosis, and 5 percent had an ?other? diagnosis. There were no statistically significant differences between the groups at baseline, except that there were more men in the AOT group than in the comparison group (67 percent versus 54 percent, respectively). Adjustments were made using fixed-effects logistic regression, which removed between-person variance and allowed within-person variance, thus controlling the effects of individual differences (such as age, gender, race-ethnicity, and education attainment), whether measured or not.

Outcomes of interest included all arrests (for any offense) and arrests for violent offenses. Official arrest data were retrieved from the New York State Department of Criminal Justice Services (DCJS) for each participant, from the date the participant turned 18 until January 1, 2007; however, the study included extended arrest records for up to 60 months prior to study recruitment, as study researchers had to verify that participants were New York residents at the time of the interview. Specifically, data records included the date of each offense and the associated charge.

A between-group analysis comparing those who had never been assigned to AOT with those who were ever assigned to AOT, at three time periods,: 1) before AOT, 2) during and 6 months after AOT, and 3) more than 6 months after AOT ended. The CrimeSolutions review of the study focused on the comparison between those never assigned to AOT and those who were currently receiving, or within the last 6 months had received, AOT. Logistic regression estimated through generalized estimating equations (GEE) was used in the between-group analysis that compared the likelihood of all arrests and arrests for violent offenses, between the AOT and comparison groups, at 6 months after AOT. The study authors did not conduct subgroup analyses.

A recent examination of assisted outpatient treatment (AOT) implemented in the Nevada County, California looked at the cost savings that resulted from 17 individuals who were enrolled in AOT during the first 2½ years of program implementation (no comparison group was included). The results showed a total cost savings of over $500,000, attributable to decreases in hospitalizations and in jail time of the 17 individuals. For every $1.00 invested in AOT in Nevada County, $1.81 was saved (Heggarty 2011).

Under Kendra’s Law, local Assisted Outpatient Treatment (AOT) programs were created to monitor and oversee the implementation of AOT requirements for New York City and for each New York State county. These local AOT programs accept and investigate reports of individuals who may require AOT; prepare and file petitions for AOT in local supreme or county courts; and prepare and approve proposed AOT treatment plans. The local programs are also responsible for oversight and monitoring of service providers, including case management services or Assertive Community Treatment (ACT) team services. The case managers and ACT team members are in charge of directly monitoring an AOT recipient’s level of compliance and delivery of services by other providers pursuant to the court order. Case managers and ACT team members report to local AOT program directors on an individual’s treatment status (New York State Office of Mental Health 2005).

The Treatment Advocacy Center (TAC) provides information on AOT. Additional information is available at https://www.treatmentadvocacycenter.org/ .

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Bush, Alisa B., Christine M. Wilder, Richard A. Van Dorn, Marvin S. Swartz, and Jeffrey W. Swanson. 2010. “Changes in Guideline-Recommended Medication Possession After Implementing Kendra’s Law in New York.” Psychiatric Services 61(10):1–6.

Geller, Jeffrey L. 2006. “The Evolution of Outpatient Commitment in the USA: From Conundrum to Quagmire.” International Journal of Law and Psychiatry 29:234–48.

Heggarty, Michael. 2011. Assisted Outpatient Treatment: Outcomes Report. Grass Valley, Calif.: Nevada County Behavioral Health Services.

New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment . Albany, NY: New York State Office of Mental Health.

Phelan, Jo C., Mariyln Sinkewicz, Dorothy M. Castille, Steve Huz, and Bruce G. Link. 2010. “Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State.” Psychiatric Services 61(2):137–43.

Robbins, Pamela Clark, Karli J. Keator, Henry J. Steadman, Jeffrey W. Swanson, Christine M. Wilder, and Marvin S. Swartz. 2010. “Regional Differences in New York’s Assisted Outpatient Treatment Program.” Psychiatric Services 61(10):1–6.

Swanson, Jeffrey W., Richard A. Van Dorn, Marvin S. Swartz, Andrew M. Cislo, Christine M. Wilder, Lorna L. Moser, Allison R. Gilbert, and Thomas G. McGuire. 2010. “Robbing Peter to Pay Paul: Did New York State’s Outpatient Commitment Program Crowd Out Voluntary Service Recipients?” Psychiatric Services 61(10):1–8.

Swartz, Marvin S., Jeffrey W. Swanson, Henry J. Steadman, Pamela Clark Robbins, and John Monahan. 2009. New York State Assisted Outpatient Treatment Program Evaluation . Durham, NC: Duke University School of Medicine.

Swartz, Marvin S., Christine M. Wilder, Jeffrey W. Swanson, Richard A. Van Dorn, Pamela Clark Robbins, Henry J. Steadman, Lorna L. Moser, Allison R. Gilbert, and John Monahan. 2010. “Assessing Outcomes for Consumers in New York’s Assisted Outpatient Treatment Program.” Psychiatric Services 61(10):1–6.

Swanson, Jeffrey W., Marvin S. Swartz, Randy Borum, Virginia A. Hiday, H. Ryan Wagner, and Barbara J. Burns. 2000. “Involuntary Out-Patient Commitment and Reduction of Violent Behavior in Persons with Severe Mental Illness.” British Journal of Psychiatry 176:324–31. (This study was reviewed but did not meet CrimeSolutions criteria for inclusion in the overall program rating.)

Gilbert, Allison R., Lorna L. Moser, Richard A. Van Dorn, Jeffrey W. Swanson, Christine M. Wilder, Pamela Clark Robbins, Karli J. Keator, Henry J. Steadman, and Marvin S. Swartz. 2010. “Reductions in Arrest Under Assisted Outpatient Treatment in New York.” Psychiatric Services 61(10):1–4. (This study was reviewed but did not meet CrimeSolutions criteria for inclusion in the overall program rating.)